Real-Time Intravascular Ultrasound-Guided Percutaneous Coronary Intervention for Spontaneous Coronary Artery Dissection

BACKGROUND: Spontaneous coronary artery dissection (SCAD) causes acute coronary syndrome, particularly in younger patients without traditional risk factors. Percutaneous coronary intervention (PCI) for SCAD has higher failure rates than atherosclerotic PCI, primarily due to false lumen wiring. Intravascular ultrasound (IVUS) improves safety, but the optimal wiring technique is undefined. CASE SUMMARY: A 49-year-old woman with no cardiovascular risk factors presented with unstable angina. Imaging showed proximal subtotal occlusion of the right coronary artery with TIMI flow grade 2, consistent with SCAD. IVUS in the conus branch enabled successful guidewire advancement into the true lumen. DISCUSSION: This case illustrates a novel application of side-branch IVUS to guide true lumen wiring during SCAD PCI. TAKE-HOME MESSAGES: SCAD must be considered in patients without traditional risk factors presenting with acute coronary syndrome. PCI for SCAD carries a higher risk of iatrogenic dissection propagation, mandating intravascular imaging. Real-time IVUS-guided wiring enables accurate identification of the true lumen in SCAD.